Healthcare Provider Details

I. General information

NPI: 1417759788
Provider Name (Legal Business Name): CENTRAL COAST EMOTIONAL WELLNESS LICENSED CLINICAL SOCIAL WORKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 E CHAPEL ST
SANTA MARIA CA
93454-4522
US

IV. Provider business mailing address

616 E CHAPEL ST
SANTA MARIA CA
93454-4522
US

V. Phone/Fax

Practice location:
  • Phone: 805-400-3721
  • Fax: 805-614-7126
Mailing address:
  • Phone: 805-400-3721
  • Fax: 805-614-7126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: GIZELLE MENDOZA
Title or Position: PRESIDENT
Credential: LCSW
Phone: 805-400-3721